Use of a Lysine-Derived Urethane Surgical Adhesive as an Alternative to Progressive Tension Sutures in Abdominoplasty Patients: A Cohort Study.

BACKGROUND: Fluid accumulation is a common complication after abdominoplasty procedures, and is typically managed by the placement of post-surgical drains. Progressive tension sutures (PTS) have been shown to be an effective approach to reduce the dead space by point-wise mechanical fixation, allowing for drain-free procedures. Lysine-derived urethane surgical adhesive provides an alternative approach for mechanical fixation and reduction of dead space, and may reduce surgery time compared to PTS. OBJECTIVES: This prospective, controlled, single center clinical study compared progressive tension suture wound closure technique without drains (control) to tissue adhesive wound closure technique without drains (test) during abdominoplasty surgery. The objective was to determine if lysine-derived urethane surgical adhesive is an effective alternative to PTS for drain-free abdominoplasty procedures. METHODS: Patients undergoing abdominoplasty who met the established inclusion/exclusion criteria were consented and enrolled in the study. Ten PTS (control) cases were performed, followed immediately by 10 tissue adhesive (test) cases. RESULTS: Surgeries were completed over an 8-month period. No statistical differences were identified between the two groups with regard to age, BMI, dissection surface area or flap weight. No clinical seroma formation was observed in either group. In the control (PTS) group, two patients developed small areas of dermal closure suture abscess requiring removal of suture material. One control patient developed drainage and fat necrosis thought to be related to PTS above the incision and later required a scar revision. One tissue adhesive patient developed hypertrophic scars of both her breast reduction and abdominoplasty scars requiring additional treatment. CONCLUSIONS: Lysine-derived urethane surgical adhesive was applied in less time than PTS, even after accounting for holding pressure for 5 minutes. The tissue adhesive provided four times the number of attachment points compared to PTS, although the significance of this is not clear. Based on these results, the use of lysine-derived urethane surgical adhesive was found to be a safe and effective alternative to PTS to reduce seroma formation in drain-free abdominoplasty procedures.

Decrease in Seroma Rate After Adopting Progressive Tension Sutures Without Drains: A Single Surgery Center Experience of 451 Abdominoplasties Over 7 Years.

BACKGROUND: Abdominoplasty is a common aesthetic procedure in the United States. Pollock and Pollock described their progressive tension technique in 2000 and published a series of 597 patients in 2012 of their experience. The reported seroma rate in the literature ranges from 2% to 26% with drains and 0.1% to 4% with progressive tension sutures (PTS) without drains. OBJECTIVES: Given these data, we decided to use PTS and forego drains in abdominoplasty. Here we present our experience with the transition. METHODS: This is a retrospective chart review of 451 abdominoplasties performed at our outpatient surgery center over a 7-year period (2009-2015). We gathered data on patient demographics, concomitant liposuction, and complications and length of follow up. RESULTS: Five main differences were examined in PTS vs traditional abdominoplasty using drains groups. These included rate of seroma, wound complication, scar revision, hematoma, and follow up. We found a decreased rate of seroma in the PTS group, 2% vs 9%. Wound complications were similar. Scar revision was slightly higher in the PTS group at 17% vs 10% in traditional abdominoplasty, this association had a P value of .048. The rates of hematoma were similar (0% vs 1%). The mean follow up was 6 months in PTS and 9 months in traditional abdominoplasty. Addition of liposuction did not increase the rate of seroma. CONCLUSIONS: PTS without drains significantly decreased the seroma rate in our practice. Our experience adds to the mounting evidence that surgeons should consider using the PTS technique and abandon the use of drains in abdominoplasty. A well powered, multicenter, randomized controlled study is needed in order to definitively lay this question to rest. LEVEL OF EVIDENCE: 4 Therapeutic.

Strategies and Challenges in Simultaneous Augmentation Mastopexy.

Simultaneous breast augmentation and mastopexy is a common procedure often considered to be one of the most difficult cosmetic breast surgeries. One-stage augmentation mastopexy was initially described more than 50 years ago. The challenge lies in the fact that the surgery has multiple opposing goals: to increasing the volume of a breast, enhance the shape, and simultaneously decrease the skin envelope. Successful outcomes in augmentation can be expected with proper planning, technique, and patient education. This article focuses on common indications for simultaneous augmentation mastopexy, techniques for safe and effective combined procedures, challenges of the procedure, and potential complications.

Superior pedicle technique of reduction mammaplasty: a stepwise approach.

Numerous surgical options for breast reduction have been described, but in the current healthcare environment, efficiency is of the utmost importance. In this Featured Operative Technique, the authors describe an efficient, reproducible, and simple method for minimal to moderate reduction mammaplasty that utilizes a superior pedicle. The surgical maneuvers were developed and conveyed to the senior author (W.G.S.) by Dr John Bostwick. This approach preserves superior and medial breast fullness while providing appropriate resection of the breast parenchyma to ameliorate symptoms and produce a smaller, lifted breast with a more youthful appearance. The surgical technique maintains a reliable blood supply to the nipple-areola complex (NAC) from the internal mammary artery and its perforators, and involves minimal transposition of the NAC. The authors reviewed the charts of 62 consecutive patients who underwent this procedure and found the complication rate to be 11.3%. Complications included 1 hematoma, 1 standing cone deformity, 3 soft-tissue infections, 8 incisional breakdowns, and 1 unilateral necrosis of the NAC.

Secondary augmentation-mastopexy: indications, preferred practices, and the treatment of complications.

Increasing the volume of the breast while simultaneously decreasing the skin envelope equates to surgery involving opposing forces. Increasing patient demand and the evolving perceptions of surgeons have led to the growing popularity of the combined augmentation-mastopexy operation. In turn, secondary augmentation-mastopexies and revisional surgeries of primary augmentation-mastopexies also have increased in popularity. In this article, the authors describe indications for secondary augmentation-mastopexy, techniques for performing this combined procedure safely and effectively, adjunctive procedures, potential pitfalls, and the treatment of complications.

One-Stage Augmentation Mastopexy: A Review of 1192 Simultaneous Breast Augmentation and Mastopexy Procedures in 615 Consecutive Patients.

BACKGROUND: Despite the increasing popularity of the combined augmentation mastopexy procedure among patients, the safety and efficacy of this surgery have been questioned by many surgeons. OBJECTIVE: The authors investigated the safety and efficacy of the combined augmentation mastopexy procedure. METHODS: The authors retrospectively reviewed the medical records of 615 consecutive patients who underwent combined augmentation mastopexy procedures at a single outpatient surgery center from 1992 through 2011. Patient demographics, operative and implant details, and long-term outcomes were analyzed. Rates of complications and revisions were calculated. RESULTS: The most common complications were poor scarring (5.7%), wound-healing problems (2.9%), and deflation of saline implants (2.4%). Of the 615 patients evaluated, 104 (16.9%) elected to undergo revision surgery: 54 revision procedures were secondary to implant-related complications, and 50 were secondary to tissue-related complications. Our data compare favorably with previously reported revision rates for breast augmentation alone and mastopexy alone. CONCLUSIONS: With a skilled surgeon and proper patient selection, the combined augmentation mastopexy procedure can be safe and effective. LEVEL OF EVIDENCE: 4.

Broad overview of a clinical and commercial experience with CoolSculpting.

BACKGROUND: Cryolipolysis has been shown to be a safe and effective noninvasive procedure for the reduction of localized subcutaneous fat. OBJECTIVES: The authors examine the safety, efficacy, and procedural growth of cryolipolysis (via the CoolSculpting device; Zeltiq, Pleasanton, California) in a single plastic surgery practice. METHODS: A retrospective chart review was conducted for 528 consecutive patients who underwent cryolipolysis treatment from January 2010 to December 2012. The number of patients, the number of treatment cycles, the average number of cycles per patient, all treatment areas, and all procedural complications were recorded and analyzed. Overall practice growth with the device was also analyzed. RESULTS: Over the study period, 1785 anatomic sites were treated with 2729 cycles, primarily in the lower abdomen (28%, n = 490 cycles), upper abdomen (11%, n = 189), left flank (19%, n = 333), right flank (19%, n = 333), inner thigh (6%, n = 111), outer thigh (5%, n = 87), and back (6%, n = 99). The age distribution for men and women was similar (46.6 ± 12.8 years for women and 46.5 ± 12.3 years for men; overall range, 18-79 years). Only 3 cases of mild or moderate pain/neuralgia were reported and resolved in 4 or fewer days. No adverse events were reported. Procedure volume showed consistent growth, with treatment cycles increasing by 823% by 2012. CONCLUSIONS: Based on the results in this single plastic surgery practice, cryolipolysis is a safe and effective nonsurgical body contouring method associated with high patient satisfaction that can generate steady, significant business growth.

Outpatient reduction mammaplasty: an eleven-year experience.

BACKGROUND: In the last 15 years, reduction mammaplasty has been increasingly performed on an outpatient basis. Despite this evolution, few outcome studies have been published regarding outpatient breast reduction surgery. OBJECTIVE: The authors documented clinical outcomes of reduction mammaplasty performed in an outpatient setting over an 11-year period and compared these results with published normative values in the plastic surgery literature. METHODS: A retrospective review was undertaken of 884 reduction mammaplasties in 444 patients at a single outpatient surgical center performed by the senior author (W.G.S.) from 1995 through 2006. In all cases, a laser-assisted, inferior pedicle, Wise pattern, reduction mammaplasty was performed. In addition to demographic and surgical data, complication frequency and type were recorded. Complication data were further stratified into minor and major categories. Potential minor complications included seroma, hematoma, soft tissue infection, dog-ears requiring revision, and small incisional breakdowns or delayed healing of less than 2 cm. Potential major complications included large incisional breakdowns or delayed healing of greater than 2 cm, nipple/areolar necrosis, need for blood transfusion, deep vein thrombosis, pulmonary embolus, myocardial infarction, and death. RESULTS: The mean patient age was 38 years (range, 16 to 73 years). Mean body-mass index was 27 (range 17 to 47). The reported preoperative brassiere cup sizes ranged from a 34 C to a 38 K, with a DD being the most common size. The mean preoperative sternal notch-to-nipple distance was 29 cm (range 22 to 54 cm). Forty patients smoked (9%). Mean clinical follow-up was 13 months. Mean total resection weight of breast tissue was 1228 g (range 100 to 5295 g). Mean operative time for reduction mammaplasty was 115 minutes (range 50 to 195 minutes). Nineteen percent of patients underwent multiple procedures, including abdominoplasty, lipoplasty, and facial procedures, with a mean operative time of 132 minutes (range 75 to 345 minutes). The overall complication rate was 14%, with 70 minor complications occurring in 62 patients. Specific minor complications included one seroma, four hematomas, eight soft tissue infections, two of which required a short course of intravenous antibiotics, one patient with dog-ears requiring surgical revision, and 56 small incisional wound breakdowns (< 2 cm). The small incisional breakdowns, which represented the largest group of complications, were further subdivided into 44 minor T-zone wounds, 3 nipple-areolar complex wounds, and 9 wounds of the vertical and horizontal incisions. Three major complications (0.67%) were recorded. Two patients had development of partial nipple/areolar necrosis. A third patient required anticoagulation for a pulmonary embolus diagnosed 10 days after surgery. Statistical analysis of the complication data revealed one significant relationship. Patients with a body mass index above the mean had a 21% complication rate as compared with a 12% rate for those below the mean. Of note, there was no increase in complication rate in the context of multiple procedures. CONCLUSIONS: This retrospective series is the largest to date involving outpatient reduction mammaplasty. Complication data derived from this series are comparable to previously published studies and thus support the safety and efficacy of outpatient reduction mammaplasty performed in an accredited facility.

Exploring the effect of the referring general surgeon's attitudes on breast reconstruction utilization.

BACKGROUND: Breast reconstruction rates remain low, at 5%-15% of mastectomy patients, despite the safety and high patient satisfaction of these procedures. Reasons for this are multifactorial, including the attitudes and biases of the referring breast surgeon, as well as patient factors. The purpose of this study was to explore attitudes of general surgeons towards breast reconstruction. METHODS: We surveyed 369 general surgeons in Wisconsin with questions about breast surgery. Responses from 135 (36%) surgeons were analyzed. RESULTS: Seventy-three percent of the respondents performed at least some breast surgery and were eligible for the study. For a little over 50% of the general surgeons surveyed, breast surgery made up less than 10% of their practice. Fifty-one percent never performed a skin-sparing mastectomy. A large number of breast surgeons (40%) did not refer all mastectomy patients for reconstruction. Reasons cited for not referring patients included the concerns over cancer recurrence and advanced patient age. Reasons for patients not undergoing reconstruction included patient's refusal, need for radiation therapy, delaying adjuvant oncologic treatment, patient factors, and having no plastic surgeon available locally. CONCLUSIONS: The decision by a patient to undergo breast reconstruction involves many complex factors. As a specialty, we should focus on improving the availability of breast reconstructive surgeons and educating referring surgeons and patients about reconstructive indications and options in order to positively affect the utilization of breast reconstruction.

Office-based plastic surgery with general anesthesia: efficiency of cost and time.

Office-based plastic surgery with general anesthesia has several benefits compared with hospital-based surgery. Office-based procedures can be done in a safe, cost- and time-efficient manner, with improved convenience for both the surgeon and the patient. A review and discussion of outpatient plastic surgery procedures at the Marina Outpatient Surgery Center in Marina del Rey, California, was performed.

Ten years of outpatient abdominoplasties: safe and effective.

BACKGROUND: Abdominoplasty has traditionally been described in the literature as an operation that is performed in a hospital setting, although more recently it is likely that most procedures are performed on an outpatient basis. To date, there have been very few large series illustrating the safety and efficacy of abdominoplasty performed in outpatient surgery centers. OBJECTIVE: This study reports the complications and revisions of outpatient abdominoplasties in a large patient population. METHODS: The charts of 519 consecutive abdominoplasty procedures performed at a single outpatient surgical center over the past 10 years (1996-2006) were reviewed. Follow-up was 6 months to 10 years, with an average of 4.3 years. Mean age at the time of operation was 43 years; range 19 to 74 years. Gender, smoking history, American Society of Anesthesiologists risk score, body mass index, type of abdominoplasty, and concurrent procedures were recorded. Each patient's chart was reviewed to assess complication and revision rates, including deaths, venous thromboembolism events, wound dehiscence, infection, seroma, hematoma, and scarring unacceptable to the patient or surgeon. RESULTS: The most common complication was seroma (10.6%), followed by unacceptable scarring of the abdominal or umbilical incisions (7.9%). The most common reason for revision was abdominal scar revision (6.4%). Most patients had concurrent additional procedures at the time of abdominoplasty, most commonly lipoplasty (91%). There was no statistically significant difference in complications or revisions when comparing groups based on age, body mass index, operating room time, smoking status, full abdominoplasty versus a less complex procedure such as a "mini" or floating umbilical abdominoplasty or simultaneous procedures. Men were significantly less likely to have a complication when compared with women. CONCLUSIONS: This large retrospective study of 519 consecutive abdominoplasty procedures performed on an outpatient basis demonstrates that abdominoplasties may be performed safely and effectively at an accredited outpatient surgery facility.

A review of 100 consecutive secondary augmentation/mastopexies.

BACKGROUND: Simultaneous breast augmentation and mastopexy has historically been a controversial topic, and it has been considered by some to be a difficult and unpredictable procedure. Secondary breast augmentation and mastopexy after previous breast surgery is rarely discussed in the literature, and little is known about the outcomes of these secondary procedures. OBJECTIVE: The authors present the indications, surgical techniques, and outcomes in a series of 100 consecutive secondary simultaneous breast augmentation and mastopexy cases. METHODS: One hundred consecutive patients who underwent secondary combined augmentation mammaplasty and mastopexy from 1992 to 2005 were retrospectively reviewed. The complications and revision rates in this group of patients were analyzed and compared with primary mastopexy alone, as well as with primary combined augmentation and mastopexy. Independent variables such as patient age, history of smoking, body mass index, type and size of implant, and type of mastopexy incision were analyzed for correlation with complication and revision rates. RESULTS: No major complications were noted in an average of 3.5 years follow-up (range 13 months to 13 years). Minor complications occurred in 13 patients, of whom 8 required revision surgery. The most common tissue-related complications were poor scarring (3%) and recurrent ptosis (3%). The most common implant-related complications were infection (3%) and capsular contracture (2%). In addition, 6 patients underwent reoperation for implant size exchange, and 1 patient underwent revision surgery to receive silicone implants. Patient age, history of smoking, body mass index, type and size of implant, type of mastopexy incision, type and number of previous breast surgeries, surgical time, concurrent non-breast operations, and preoperative ptosis grade were not statistically significant risks when correlated to the complication and revision rate. CONCLUSIONS: Simultaneous breast augmentation and mastopexy after previous breast surgery is a commonly performed procedure that is not adequately reported in the literature. Our study indicates that the procedure is safe and has complication and revision rates comparable to primary augmentation/mastopexy.

Pediatric feeding disorder and growth decline following mandibular distraction osteogenesis.

BACKGROUND: Mandibular distraction osteogenesis has proven to be an effective treatment for upper airway obstruction related to micrognathia. Changes in the aerodigestive space can help facilitate tracheostomy removal in children and prevent tracheostomy in newborns. However, this may also precipitate changes in the ability to orally feed. There are few data on early postoperative feeding and growth rate following mandibular lengthening. The authors found evidence of growth rate decline and feeding difficulty in pediatric patients following mandibular distraction osteogenesis. METHODS: Ten pediatric patients underwent mandibular distraction osteogenesis for treatment of upper airway obstruction. Outcomes in resolution of upper airway obstruction, oral feeding success, and growth rate were analyzed. Follow-up ranged from 12 to 28 months. RESULTS: All 10 patients had complete resolution of upper airway obstruction. The length of distraction ranged from 10 to 17 mm. Three patients demonstrated a feeding disorder after mandibular distraction osteogenesis, defined as requiring a long-term (>1 month) alternate feeding method (gastric tube in two patients and gastric gavage in one). Seven of 10 patients exhibited an early decline in growth rate following distraction. Data used to determine growth rate changes were weight measurements at the time of distraction, at the time of distractor removal (6 to 8 weeks after distraction), and at 6 and 12 months after the date of distraction initiation. CONCLUSION: These results suggest that infants and children undergoing mandibular lengthening by distraction osteogenesis should be carefully monitored for postdistraction feeding disorder and growth rate disturbance.

Venous thromboembolism in plastic surgery patients: survey results of plastic surgeons.

BACKGROUND: Recommendations for venous thromboembolism (VTE) prophylaxis have been published in the plastic surgery literature. However, no comprehensive survey of the overall incidence of VTE among plastic surgery patients has been undertaken. OBJECTIVE: This study was performed to determine the incidence of VTE in plastic surgery patients, to delineate which procedures have the most risk for VTE, and to establish whether published guidelines are utilized by plastic surgeons. METHODS: An e-mail survey was sent to 3797 plastic surgeons based in the United States. Of those queried, 1106 (29%) completed the questionnaire. Respondents were asked to report VTE events in their patients over the last 24 months. There were 8 patient-based questions about VTE prophylaxis to determine the preferred method used. RESULTS: Overall, 329 VTE events were identified. The most commonly associated procedures were abdominoplasty with another procedure (87 events) and abdominoplasty alone (71 events). Whether abdominoplasty is performed alone or combined with another procedure, the survey revealed similar rates of VTE per 10,000 patients (36 events per 10,000 patients). Plastic surgeons' prophylaxis methods vary, and 38% of the respondents were not aware of the published recommendations. CONCLUSIONS: Based on our study, abdominoplasty with or without a second procedure has the highest incidence of VTE events among plastic surgery procedures. Combining abdominoplasty with another procedure does not increase the risk for VTE. A significant number of plastic surgeons are not aware of the published recommendations, and there is no consistent VTE prophylaxis used by the plastic surgeons who responded to the survey.

Cutaneous vascular lesions.

Vascular anomalies are lesions seen in all surgical disciplines, particularly in pediatric patients. Specialization in vascular anomalies involves a team effort, with the team consisting of plastic surgeons, general surgeons, neurosurgeons, pediatricians, interventional radiologists, dermatologists, ophthalmologists, otolaryngologists, hematologists, and pathologists. Inconsistent nomenclature in the literature has historically resulted in confusion about classification, diagnosis, and treatment. A biologic classification system has emerged, based on clinical observations, natural history, and cellular features, which separates vascular anomalies into two broad categories: vascular tumors and vascular malformations. For many vascular anomalies, photodocumentation, psychosocial support, and communication are important throughout the treatment course.

Influenza A virus-associated acute necrotizing encephalopathy in the United States.

During the past several years, influenza-associated acute necrotizing encephalopathy has been well-recognized in Asia but has not yet been reported in the United States. We describe a 28-month-old patient who displayed the classical clinical features of acute necrotizing encephalopathy in association with a documented influenza A infection. This disease is characterized by fever, a rapid alteration in consciousness and seizures, with radiologic involvement of the bilateral thalami and cerebellum.